Stuart Douglas became Director of Specialist Estates Services (SES), part of NHS Wales Shared Services Partnership (NWSSP), just over a year ago, having been Deputy Director since August 2022. HEJ editor, Jonathan Baillie, recently met up with him by ‘Teams’ to find out more about his career, and discuss some of the most pressing issues facing the healthcare estate management and healthcare engineering community across the Principality, and his thoughts on future challenges and opportunities for the sector in Wales
Beginning an interesting discussion, Stuart Douglas explained that he took over as Director, NWSSP SES on 1 March 2023, following Neil Davies’s retirement. He said: “Neil was a very-well known and highly respected leader of NWSSP SES. He was also six feet nine tall, so I knew I had some big boots to fill – literally and metaphorically – when I took up the job.
A quantity surveyor by background, Stuart Douglas explained that in the mid-1980s he worked in construction consultancy roles in the retail sector. However, when this work contracted later that decade, his focus shifted to work in the public services arena. He said: “I became especially fascinated with development on hospital sites, and was also keen to broaden my project management experience. I had previously worked in a multidisciplinary design practice, and later at health focused-practices, where I developed my love of working in healthcare.” As his project management skills burgeoned, he increasingly found himself talking to heads of departments and disciplines, discovering how they worked, and helping them plan new or rationalised facilities. He said: “I absolutely loved it; I was effectively being paid to learn. I then became more involved in developing wider strategic plans.”
Experience in the mental healthcare sector
In 1995, he joined mental healthcare services provider, Bath Mental Healthcare NHS Trust: “Bath Mental Healthcare was initially host to a shared service of Project Managers and Property Advisors called Capitec, which was later absorbed into NHS Estates and launched as ‘Inventures’ – a national estates consultancy service,” he explained. From 2004-2018 he ran his own estates and facilities strategic advice consultancy – undertaking gateway reviews, estates strategies, and business cases, and taking on planning and delivery of major capital project and programmes. Travelling extensively throughout Englandand Wales, he kept in contact with Pat Riordan (NWSSP SES Deputy Director, Strategic Planning and Construction) and Neil Davies (then Director) at NWSSP SES, and they commissioned him to write the project team duties for the original Design for Life Building for Wales Framework. He said: “That educated me about how projects would be delivered in Wales.”
Joining NWSSP SES as Head of Estates Development in 2018, he rapidly integrated into the team providing advice to Welsh Government and health organisations across the nation – which remains a key activity for him today. In August 2022 he was promoted to Deputy Director and Chief Estates Advisor to Welsh Government, to support the Director in overseeing delivery of the full portfolio of SES services, becoming Director in February 2023. He has an Honours Degree in Quantity Surveying, a Postgraduate Diploma in Leadership, is a Chartered Quantity Surveyor, a Member of the Association for Project Management, and an NHS Estates Accredited Project Director for major development schemes in the NHS.
Leaving his consultancy
Of his decision to leave consultancy work, he said: “I’d been privileged to have a very broad level of involvement, working with NHS Trusts and Health Boards across England and Wales, and on joining NWSSP SES this stood me in excellent stead. There was a broad and interesting mix of issues to address – from scrutinising business cases and estate strategies, to coordinating provision of advice from the various specialist disciplines.” He continued: “My current role is varied. One minute I can be working directly on schemes of a few hundred thousand pounds, and the next I may be looking at national estates policy issues, or advising on plans for investing over £1 bn in new facilities. It’s all about balancing the apportionment of my own and my team’s time. We have a team of 50+ spread over a number of sections – Property, Engineering, Construction Procurement, and Estate Development, with a wide array of sub-specialisms.
Backlog maintenance and RAAC
Here we moved to discuss some of the ‘big issues’ for Stuart Douglas and his team, and the wider healthcare EFM/engineering sector, in Wales, beginning with a perennial one – backlog maintenance. He said: “The current backlog figure in Wales is £1.2 bn, excluding RAAC remediation work. We’ve made good progress in ascertaining the presence and condition of RAAC, having begun working with Health Boards in 2019. With the encouragement of Welsh Government, we have pushed them as hard and fast as we can in our advisory role to make this a priority.” He continued: “There are two ‘live’ hospitals in Wales with extensive RAAC at present – Nevill Hall Hospital in Abergavenny, and Withybush Hospital in Haverfordwest
“At Withybush,” Stuart Douglas explained, “the RAAC is over a two-storey building, and they are fixing Unistrut type supports etc. to stabilise the full area of the impacted structure, in phases. At Nevill Hall Hospital, similar works will be done, but concentrating investment on the areas of estate which will be required for the longer term to reflect the Health Board’s service and estates strategy. However, as applies elsewhere with RAAC, just because people put in straps and braces, doesn’t mean you can then walk away and have another trouble-free 10 years. Facilities will need to be regularly monitored, and hopefully they will last long enough for longer-term solutions to be developed.”
I next asked about the wider backlog issue. Stuart Douglas replied: “It’s widely recognised that this is now a material problem. I watched the backlog figure rise from my arrival in 2018 onwards. EFM colleagues recognised its seriousness, but when it topped £1 bn, that milestone really resonated with people more widely. Having increased from £1 bn to £1.2 bn over the last year, one could envisage it won’t be too long before we hit £2bn, and it’s going to be a challenge to reverse the trend. There are so many demands on our capital – for new services, expanding existing ones, and new equipment, all soaking up the available resources. We’re now in a position where we develop more estate, but are not shedding it sufficiently quickly, to maintain it with the resources we have available. It’s tough; you can’t easily ask a Health Board not to invest in expanding a service in response to demand because you’ve got to replace the windows in its tower block. They’re being pulled in many directions.”
Stuart Douglas said a ‘far-sighted’ measure implemented a few years ago had been the Welsh Government’s creation of an Estate Modernisation Fund of £34 m – that Health Boards could bid for to address fire, mental health, fabric, and environmental issues. He explained: “Then, two and a half years ago – having reflected on the outcome – Welsh Government developed a new arrangement offering £40 m based on a 70/30 split – Health Boards had to come up with £17 m, and could bid for investment again in broadly the same categories. They consequently began making inroads into their existing allocations to prioritise the estate, which is what Welsh Government wanted to see. It’s been highly successful, but in terms of arresting a £1.2 bn problem, it’s not enough – and that’s widely understood. Something must change.”
When he presented at last May’s Wales Regional Conference in Cardiff, Stuart Douglas emphasised the importance of having good, accurate, and up-to-date data on the estate’s condition to identify and address the most serious risks. He said: “The guidance requires organisations to thoroughly review the condition of their estate every five years, with interim reviews to check on condition and identify any emerging issues in between – but not all organisations have been able to do this. At times in the NHS we commission surveys, but don’t get a consistent quality or format of report. We’ve been investigating potential solutions with the other devolved nations and NHSE/I. For the interests of Wales, we’re going to appraise solutions including recruiting people in house, creating a framework, or collaborating with the other nations to produce a shared resource for use UKwide. It’d be great to have a standardised approach to recording this data, so we can share it effectively.”
Wales’s EFPMS system
Wales’s equivalent of England’s ERIC (Estates Returns Information Collection) system is the EFPMS – the Estates and Facilities Performance Management System. Stuart Douglas said: “It’s been developed from ERIC to suit our needs. We started developing it to introduce decarbonisation measures, but we recognise that in England and Scotland respectively the EFM communities have adopted the PAMS and SAMS methodologies. While we’re all busy in Wales, we’re trying to create an environment where we can constantly look at the performance of the estate; thus instead of a one-year ‘snapshot’, we’ll have a live model, showing condition, highest risks, and a picture of operational compliance. In the coming year we want to appraise what’s on offer and decide what can realistically be adopted. The time has come – especially with an ageing estate – to be able to start being clearer about where the risks are, but also to be able to provide assurance that the issues are being managed correctly.”
At May 2023’s IHEEM Wales Regional Conference, Stuart Douglas mentioned that NWSSP Services had begun working with Welsh Government to produce ‘heatmaps’ of particular sites and regions within the Welsh NHS where estate investment is most needed. He said: “As a service we produce spreadsheets, which I personally find easy to use to visualise particular hotspots. Colleagues elsewhere, however, are not so keen, and need to be able to view more visual representations.” He showed me screenshots of a number of the ‘heatmaps’ so far produced, which illustrate, using different-coloured circles for each Health Board, the sites with the biggest backlog and estate risk issues. Another ‘more busy’ slide showed sites with low and high voltage electricity resiliency issues. He added: “We already knew certain sites needed attention, but the heatmaps are great for showing Welsh Government and the Health Boards what the relative positions are, and thus being able to explain why and how we’ve prioritised intervention monies.”
Making public services more ‘joined-up’
On a different note, I asked about progress in Wales with a goal I know applies UKwide – making public services as ‘joined up’ as possible – such as by better linking health and social care. Stuart Douglas said: “We are trying, and I think COVID made health and social care talk more, which has continued. However, there’s a further challenge about how we approach sharing resources – not just the estate, but across the board. Think about England, with its Integrated Care Systems.” He continued: “In Wales we have a similar models to integrate social care and health, which is good, but there’s much more we could do.” I asked for examples. Stuart Douglas said: “Sharing the estate, looking at how we use it and break down the barriers that exist in – for example – being able to enter a local authority building, plug in a laptop, and continue working as if in your office. It’s happening to some extent, but we need to push on. People need to understand that when we put up a building (at considerable cost) it exists ‘24/7’, but that – at best – we probably only use it 30% of the week. We can then start properly planning how we use resources better. We’re actively supported in this role by Welsh Government’s interagency property forum, Ystadau Cymru.”
He highlighted a collaborative opportunity to build a new regional health park in Llantrisant, to focus predominantly on day elective and diagnostic work. He said: “The location is on the M4, and we have the Cwm Taf Morgannwg, Aneurin Bevan, and Cardiff Health Boards collaborating on the plans. The facility should achieve a high throughput, but success will be dependent on ensuring that services on other sites, workforce, and estate, are reconfigured around it to maximise the potential benefits of this project.” The three Health Boards are currently putting together a Strategic Outline Case. He added: “I think it’s very positive that Rhondda Cynon Taf County Borough Council and Cwm Taf Morgannwg University Health Board worked very closely to identify the site – and its opportunities. The next stage will be for the three Health Boards to continue their collaboration and make this a success.”
On the wider healthcare estate front, I asked if he feels there has been sufficient focus on updating the mental healthcare estate in Wales. He said: “We have several reasonably large projects, at different stages of development. The more advanced one approaching Full Business Case approval is at the Ysbyty Glan Clwyd site in north Wales. It will see the redevelopment of adult and older adult mental health facilities for circa £100 m. Other proposals are being developed for significant investment in the south-east and south-west, but the exact details are yet to be determined. I think there’s a recognition of the need to invest in mental healthcare facilities. Having seen mental health and learning disabilities accommodation, I know that if care is provided in modern facilities, with single en-suite rooms, and the right components to limit ligature risks, and if staff have good sightlines, and service-users access to good therapeutic facilities, they can be a great place. Conversely, in some of the older estate, risk increases, and you then need more staff ‘checking’ patients, rather than being able to treat and work with them.”
Recruitment challenges
I next asked Stuart Douglas here what he thought the biggest current challenges were for estates and facilities personnel in the Welsh NHS. He said: “One of the most urgent is around our workforce – we need to train and develop our own, both at operative and management levels. One of our recent successes has been for our Head of Property (Clive Ball) to work with the University of South Wales to set up their Real Estate degree course. It’s one of several workstreams we are following to be able to ‘grow our own’ in the field. However, we need this across the trades. We’ve a very high age profile across NHS Wales, with a large proportion of our professional and tradespeople set to retire in the next 10 years, and it typically takes at least five years to get new entrants trained and qualified.”
I wondered what he feels are some of the biggest obstacles to attracting new entrants to healthcare EFM and engineering roles. He said: “Comparative pay rates for similar roles in the private sector may be a factor, but we are also competing for people across a wide range of activities. I think there’s the opportunity to really showcase the fantastic things we do. Our hospitals are full of complex engineering elements – high voltage power, transformers, back-up generators, massive boilers, heating and airconditioning plant, and sterilisers etc.”
He continued: “Some of the things we’re dealing with are really exciting. Joel Holley, one of our trainees, won an award for his contribution during an unplanned shutdown following an accident at one of our hospitals in South Wales, when he stayed on site through the night, working to restore power. The Director of Estates at his placement was thrilled with his professional attitude, and when you’ve patients that need to be treated, having that pressure is exciting.”
Network75
Stuart Douglas explained that Joel is one of a number of NWSSP’s Network75 students, and is studying for an Electrical Engineering degree. He said: “In recent years we’ve had seven students join us as Network75 trainees, mainly in mechanical and electrical engineering, but some now in surveying.” (‘Network75’ is a combined work placement and part-time study route to a degree allowing students to ‘Work, Earn and Learn’ run by University of South Wales). He continued: “These young people are really talented, but we need more.” I asked him what role a professional engineering institution like IHEEM could play in addressing such recruitment challenges? He replied: “I think it can play a significant role. IHEEM is, for instance, beginning to move into accreditation, and I’ve seen that happen with decontamination. I’m really impressed with IHEEM. The Institute does some fabulous work. I’ve known Pete Sellars for many years, and he’s passionate about what IHEEM does to support good professional estate management and engineering in healthcare.”
I had also spoken to Stuart Douglas previously about what UK healthcare EFM and engineering professionals can learn from other countries. He said: “IHEEM also has a key role here in inviting people from healthcare systems abroad to come and present to us. Such knowledge-sharing is invaluable.”
Stuart Douglas has also spoken regularly about the need for the NHS in Wales to free up or dispose of underutilised space, and benefit from the resulting savings. He said: “Following a Welsh Government request, this financial year we’ve gone to Health Boards and NHS Trusts and asked them for proposals for a rationalisation of their non-clinical space. We’re now evaluating these. You can imagine there’ll be a range of ambition, and it will be an iterative process.” Stuart Douglas explained that NWSSP SES has also purchased a product called OccupEye, from fm:systems, which uses sensors fitted under desks or on meeting room walls in particular areas. The associated software then provides the user organisation with a clear picture of its space utilisation. He said: “It’s a great tool for opening the eyes of Health Boards on how much of the time their space is actually utilised. We’ve just received further funding so we can get OccupEye out to Health Boards, which should inform our future rationalisation processes.
“Another aspect here,” Stuart Douglas continued, “is that we have a finite clinical workforce. When we build these new facilities, there are always redistributions of workforce. What we must do – picking on Llantrisant as an example – is to consider the whole, and here demand and capacity are key. We need to focus on our existing capacity, what demand is there, and then decide what we need. There will then be the opportunity to shed space and invest our resources in making what we really need really good.”
Local resistance to closures
As occurs in many locations, I have heard of instances of local resistance when proposals surface to close often underutilised or ageing properties as part of estate rationalisation. Stuart Douglas said: “When you live in a small country, the impact tends to be felt more. In the future though, we can explore the opportunity of taking our local residents on the planning journey with us, in order that they can participate in the full investment (and disinvestment) planning process. Take local people on that journey, and the chances of success increase.”
Stuart Douglas feels the important role played by healthcare engineers and healthcare estates and facilities personnel in running and maintaining healthcare facilities is at last gaining recognition, with the RAAC issue, for instance, having really made people consider the safety of their premises. He said: “This is where hospitals look to their Estates advisors; COVID did the same, with healthcare engineers and EFM personnel providing field hospitals. There’s increased awareness of the risks from our ageing estate; people are looking more to Estates Directors for accurate assessments of condition, compliance, and where, for example, the single points of failure risk are. Have we got to the point where they listen enough? That’s an ongoing journey, but Boards are certainly looking to us more to help them understand the risks.”
I next asked if he feels there is greater recognition of the need for capital funding. He said: “People have always been shouting. I’m not sure anyone’s ever said we have enough, but I try to accept it the way it comes. We have to provide a viable health model, and if it’s set at a level of investment the public wants, we must accept that this is the money available, and do it well. We must also ensure people understand the implications. We’re being asked to do more – both in activity, and breadth of service.”
Stuart Douglas pointed out there are examples of pharmacists being asked to do more. He said: “We have great opportunities to use pharmacists and their advice, and perhaps we can run clinics remotely from some of the spaces pharmacies have. We can think more imaginatively about how we provide services; it’s not always about new money. We have to grasp the nettle of changing service needs.”
I wondered how telehealth adoption is progressing in Wales. Stuart Douglas said: “There is some, but I think people are worried about confidentiality and the risks of someone being remote from you, but it’s definitely going to have to happen. I anticipate some of the forward-looking GP practices will begin operating remote clinics, lining up those they know have iPads etc. Perhaps that’s the Well Rich, but at least if they can clear that volume, others will get greater access to face to face consultations. I think there’s a long way to go – with a degree of acceptance or cultural change required from both patients and clinicians.”
A protracted planning process
When I had interviewed Stuart Douglas’s counterpart in England, Director and Head of Profession, NHS Estates, at NHS England, Simon Corben, a few months ago (HEJ – January 2024), we discussed how protracted the existing planning process can be for healthcare facilities. I asked Stuart Douglas for his standpoint. He said: “The voices on how long it can take for healthcare schemes to secure approval are as loud in Wales as in England. How many Strategic Outline Case proposals are a similar shape when they reach final stage proposals? The amounts of money people talk about at SOC stage are often some way from the costs at FBC. Organisations need to reflect on why, and when we create a Strategic Outline case, we must consider whether it embraces the full scope of what we are we going to accept? The answer is often ‘no’. We should insist that when an SOC is put together – yes it’s short and high-level, but actually the 80/20 rule applies: if you set up the Strategic Outline Case in the right way, you should be able to get a reasonable handle on scope and the broad cost envelope. Establish a good working arrangement with those required to have scrutiny, and share information openly and fully, and you could potentially reach these transition stages with not a lot to say – because you’ve been given the information as you go.
“There’s thus something we at Shared Services and Welsh Government can do on the scrutiny side to help – get involved and take a proactive view when things aren’t looking quite right. We are already taking more of a developmental role and asking to get involved more quickly. Welsh Government has recently issued guidance informing Health Boards that if they move outside a particular cost margin as they’re developing proposals, they must go straight back to Welsh Government for advice – and that’s only right.”
I next asked Stuart Douglas what he thinks have been some of the biggest impacts for healthcare engineers and estates and facilities personnel of the COVID-19 pandemic on both clinical and engineering practices. He said: “It’s certainly made people more conscious of air quality and ventilation, and it’s good to have that wider support for making sure our facilities achieve the right standards.”
The PFI model has undoubtedly benefited communities who might not otherwise have had hospitals built, but has also faced criticism. Aware that Velindre University NHS Trust’s proposed new Cancer Centre in Cardiff is being part funded by private finance, I asked Stuart Douglas about this. He said: “It’s in fact being funded by the Mutual Investment Model – a form of private finance, modified along the lines of the non-profitdistributing model pioneered in Scotland to reduce the high finance costs which had emerged in previous models. Plans for use of such models for future schemes will clearly need to take account of the risks we have experienced (building costs, interest rates etc), and their potential impacts on affordability.”
I next asked about he and his team’s biggest challenges since we emerged from the pandemic. He said: “I think helping Health Boards plan estate rationalisation, say, through the use of OccupEye, a tool we found and distributed. I think that’s been helpful. There’s been quite a call on Specialist Estates Services; we’ve been asked to work more closely with Health Boards – because they have had limited resources, and there’s been more of an ask. As a shared service, that’s what we are here for.”
What about his biggest personal achievements in recent years? He said: “It’s early days yet; I only celebrate my first year in the job at the end of February. Things that have pleased me include having access to Welsh Government advisors directly, and that they call me and my colleagues for advice. We’ve established a similar rapport with the Health Boards – a huge privilege that you can never ignore.”
Biggest opportunities
As our discussion ended, I asked Stuart Douglas what he felt might be the biggest changes to the way the healthcare estate is run over the next 5-10 years. He said: “Artificial Intelligence should probably be top of the list. Our NWSSP Corporate colleagues are looking at the opportunities with AI, and so are we in the Specialist Estates Services Division – in diagnostics and radiotherapy equipment particularly. AI will have a huge impact across the board, including in engineering and plant.”
He added: “I also think – looking ahead – that regional and multi-agency planning still needs to be something we push people more towards. There is a momentum to make us work more closely with social services and education. We know our Welsh government and Education counterparts, and need to build on this, since sooner or later there is no doubt that resources will have to be coordinated and shared – by way of estates staff, knowledge, software, technology, and learning.”